ACEP Announces New Choosing Wisely List

The campaign encourages medical specialty societies to create lists of five tests and procedures that may not be cost effective in some situations and should prompt discussion with patients in order to both educate them and gain their agreement regarding avoidance of such tests and procedures.

“As emergency physicians, we are committed to reducing health care costs while at the same time continuing to fulfill our commitments to provide the best, most efficient emergency care to millions of Americans,” said Michael J. Gerardi, MD, FACEP, president of the American College of Emergency Physicians.

Tests and Procedures to Question

1. Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation. Syncope (passing out or fainting) or near syncope (lightheadedness or almost passing out) is a common reason for visiting an emergency department and most of those visits are not serious. Many tests may be ordered to identify the cause of the problem. However, these tests should not be routinely ordered, and the decision to order them should be guided by information obtained from the patient’s history or physical examination.

2. Avoid CT pulmonary angiography in emergency department patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer. Advances in medical technology have increased the ability to diagnose even small blood clots in the lung. Now, the most commonly used test is known as a CT pulmonary angiogram (CTPA). It is readily available in most hospitals and emergency departments. However, disadvantages of the CTPA include patient exposure to radiation, the use of dye in the veins that can damage kidneys and high cost.

3. Avoid lumbar spine imaging in the emergency department for adults with atraumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition, such as vertebral infection or cancer with bony metastasis. Low back pain without trauma is a common presenting complaint in the emergency department. Most of the time, such pain is caused by conditions such as a muscle strain or a bulging disc that cannot be identified on an x-ray or CT scan.

4. Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis. Sinusitis is a common reason for patients to visit the emergency department. Most patients with acute sinusitis do not require antibiotic treatment, because 98 percent of acute sinusitis cases are caused by a viral infection and resolve in 10–14 days without treatment.